Acute monoarticular arthritis caused by herpes simplex virus and cytomegalovirus

Approach to knee effusions

The presence of an intra-articular knee effusion requires an extensive differential diagnosis and a systematic diagnostic approach. Pediatric knee effusions occur most commonly as acute hemarthroses after traumatic injury. However, the knee joint is susceptible to effusions secondary to a wide variety of atraumatic causes. Special attention is required in the atraumatic effusion to distinguish features of infectious, postinfectious, rheumatologic, hematologic, vasculitic, and malignant disease. This review discusses the various etiologies of both traumatic and atraumatic pediatric knee effusions highlighting the historical, physical examination, and laboratory characteristics to aid the emergency provider in diagnosis and initial management.

A case of arthritis caused by cytomegalovirus after kidney transplantation

Cytomegalovirus (CMV) is the leading cause of infectious complications after organ transplantation. We report the case of a 55-year-old renal transplant recipient who presented with CMV infection 2 months after transplantation. During oral ganciclovir treatment (5 weeks after interruption of intravenous ganciclovir), he experienced a sharp pain in the right shoulder. Examination was normal, but CMV antigenemia remained positive with 30 cells/300,000. He underwent a shoulder puncture, which confirmed the presence of CMV in the articular fluid after evaluation by polymerase chain reaction gene amplification. The patient recovered from his arthritis of the shoulder, and antigenemia became negative after 3 weeks of parenteral ganciclovir. We describe a CMV arthritis that occurred despite a curative treatment for CMV disease, and comment on the pathogenesis of this infection, the pharmalogical failure, and dosing or treatment duration.

Association between human parvovirus B19 and arthropathy in Belém, Pará, North Brazil

A total of 220 patients with arthropathy were selected in Belém, Pará between January 1994 and December 2000, and screened for the presence of human parvovirus B19 IgM and IgG antibodies by enzyme-linked immunosorbent assay (ELISA). A subgroup (n = 132) of patients with high levels of antibodies (either IgM+/IgG+ or IgM-/IgG+) were examined for the presence of DNA by polymerase chain reaction/nested PCR. Recent/active infection (detection of IgM and/or IgG-specific antibodies and presence of viral DNA) was identified in 47.7% of the 132 individuals with arthropathy. In our study, women were significantly more affected (59.7%) than men (35.4%) (P = 0.0006). The age group of 11-20 years (84.6%), among female patients, and 21-30 years (42.1%), among male, were those with the highest incidence rates. The analysis of the temporal distribution of B19-associated arthropaties showed a cyclic pattern, with peak incidence rates occuring at 3-5 year intervals. Significant diference (P = 0.01) was observed when comparing both the highest (39.0%) and the lowest (11.0%) seropositivity rates for the years of 1995 and 2000, respectively. The interfalangial joints of hands and feet were mostly affected, with 50.0% and 48.0% of cases among both women and men, respectively. In a smaller proportion, other joints such as those of knee, ankle, pulse and shoulder were affected. As for the duration, symptoms lasted 1 to 5 days in 54.0% of the individuals, whereas in 46.0% of them the disease lasted 6-10 days, if considered the subgroup (n = 63) of patients with recent/active infection by parvovirus B19. In our study, joint clinical manifestations occurred symmetrically. Our results indicate that B19 may be an important agent of arthropathies in our region, and this underscores the need for specific laboratory diagnosis when treating patients suffering from acute arthropathy, mainly pregnant women.

Histological appearance of the synovium in early rheumatoid arthritis

This report reviews and discusses studies on the synovial fluid and biopsy specimens of synovial membrane obtained during the first 6 weeks of synovitis that evolved into rheumatoid arthritis (RA). Five previously unreported cases are described. Early changes in the microvasculature and synovial lining seem to antedate the classical chronic inflammation of established RA. Further characterization in the joint tissues in very early RA offers opportunities for identification of exogenous triggers and may allow more appropriate targeting of early therapy to potentially reversible aspects of pathogenesis.

Elevated cytokine levels in synovial fluid of rheumatoid arthritis correlates with the presence of cytomegalovirus genome

Synovial fluid aspirated from 34 patients with symptomatic rheumatoid arthritis (RA) was evaluated for the presence of human cytomegalovirus (CMV) genomic material using polymerase chain reaction (PCR), and for levels of interleukin 8 (IL-8) and IL-6 using enzyme-linked immunoadsorbence assay. IL-8 and IL-6 levels were significantly higher in CMV DNA-positive RA patients than CMV DNA-negative RA patients and at least 10-fold higher than in both corresponding control groups of patients with osteoarthritis (OA). These findings suggest an association between elevated IL-8 and IL-6 levels and the presence of the CMV genome in RA patients.

Detection of herpesviruses by polymerase chain reaction in lymphocytes from patients with rheumatoid arthritis

OBJECTIVE

To investigate the occurrence of herpesviruses, including Epstein-Barr virus (EBV), herpes simplex viruses types 1 and 2 (HSV-1; HSV-2), and human herpesvirus 6 (HHV-6), in lymphocytes from patients with rheumatoid arthritis (RA) of less than 1 year's duration.

METHODS

The polymerase chain reaction was applied to cells isolated from synovial fluid and peripheral blood. Indirect immunofluorescence and enzyme immunoassay techniques were used to detect antibodies against EBV and HSV, respectively.

RESULTS

EBV DNA was present in synovial fluid lymphocytes from 19% (7 of 37) of the RA patients and 33% (5 of 15) of the patients with reactive arthritis (ReA). Peripheral blood lymphocytes harbored EBV DNA in 39% of the RA patients, 39% of the ReA patients, 27% of the patients with other arthropathies, and in 31% of the healthy control subjects. HSV-1, HSV-2, and HHV-6 viral DNA was not detected in cells from the synovial fluid or peripheral blood.

CONCLUSION

Our findings do not support the participation of EBV, HSV-1, HSV-2, or HHV-6 in the pathogenesis of RA. A role for the highly prevalent EBV cannot be excluded, however, since potential contributions may become manifest only when other necessary factors are involved. RA pathogenesis caused by an overproduction of the EBV virus is nevertheless highly unlikely.

Correlative studies of rheumatoid factors and anti-viral antibodies in patients with rheumatoid arthritis

An analysis of the relationship between the immune response to ubiquitous herpes family viruses, namely Epstein-Barr virus (EBV), cytomegalovirus (CMV), and varicella-zoster virus (VZV) and the presence of rheumatoid factors (RF), which are autoantibodies characteristic of patients with rheumatoid arthritis (RA), was conducted. Antibody profiles (RF, anti-viral antibodies) were monitored in the serum of the RA patients, and in normal individuals. No patient was found to have circulating RF in the absence of anti-viral antibodies. When the patients and normal controls were subdivided according to the presence of serum RF, it was found that when RF were present, the frequency of anti-CMV antibodies, but not anti-EBV or anti-VZV antibodies, was significantly higher (P = 0.02) when compared with RF-negative individuals. The titres of anti-CMV but not anti-VZV antibodies were found to increase in the RA patients with disease duration. To see if these viruses could stimulate RF production in vitro, peripheral blood mononuclear cells (PBMC) isolated from the patients and normal controls were stimulated with viral antigens. PBMC from normal controls, but not from RA patients, appeared to be responsive to viral antigen stimulation and produced RF. These data suggest that the immune response to CMV, to a greater extent than to EBV or VZV, correlates with the presence of RF.

Detection of cytomegalovirus antigens in phagocytosed serum complexes from a patient with rheumatoid arthritis, vasculitis, peripheral neuropathy, cutaneous ulceration, and digital gangrene

A patient with rheumatoid arthritis, vasculitis, peripheral neuropathy, cutaneous ulceration, and digital gangrene was studied. Circulating immune complexes were detected by C1q binding although serum complement levels were within the normal range. Immunofluorescent staining of buffy coat cells with specific antisera showed the presence of IgG and IgM in phagocytosed inclusions but complement C3 was not detected. A monoclonal antibody specific for cytomegalovirus detected antigens in phagocytosed inclusions on one occasion. These results may suggest that cytomegalovirus antigens are a hitherto unidentified component of serum complexes in patients with rheumatoid arthritis and may contribute to the pathogenesis of the vasculitic complications of rheumatoid arthritis by participating in immune complex formation.

Rheumatic manifestations in 556 patients with human immunodeficiency virus infection

We studied in retrospect the rheumatic manifestations of 556 patients with human immunodeficiency virus (HIV) infection. Eighty percent were men. Eighty-six percent were intravenous drug abusers (IVDAs), 9% homosexual, 3% partners of high-risk persons having the infection, 0.4% hemophiliacs, and 2% had no known risk factors. We found rheumatic disorders in 63 (11%) patients. The most frequent findings were myalgias and/or arthralgias (4.5%; one patient had an inflammatory myopathy), skeletal infections (3.6%), and arthralgias (1.6%). Reiter's syndrome and seronegative arthritis were present only in 0.5%, and HIV-associated arthritis and vasculitis in 0.4%, respectively. Skeletal infections were caused predominantly by Staphylococcus aureus (60%) and Candida albicans (20%). All these patients were IV drug abusers whose clinical features were similar to those previously described in skeletal infections of non-HIV-infected IVDAs. Comparing these data with other studies composed primarily of homosexual men where Reiter's syndrome is the predominant rheumatic disorder, we conclude that the type of rheumatic complaint is more related to the risk factors than to HIV itself.

Rat cytomegalovirus infection enhances type II collagen arthritis in rats

The effect of rat cytomegalovirus (RCMV) infection on type II collagen-induced arthritis was studied in DA rats. Rats were infected with RCMV 5 days before, simultaneously with, or 5 days after immunization with calf type II collagen. Control rats were either given type II collagen alone or were injected with normal rat salivary gland (NRSG) simultaneously with collagen immunization. Severity of arthritis in each limb was graded on a scale of 1-4 (maximum score 16). In 5 experiments, peak arthritis scores in the RCMV groups were twice those of the control groups which received NRSG or collagen only (8-9 versus 4-6). Radiographs of involved joints showed greater destruction of cartilage and articular bone in the RCMV rats than in the NRSG control group. Repeated attempts to culture RCMV from joint tissues were unsuccessful. Our results indicate that RCMV infection enhances the arthritic process in this experimental model of an autoimmune arthritis.

Infectious arthritis in renal transplant patients

Infectious complications in the renal transplant patient are common, and infecting agents include opportunistic organisms as well as common pathogens. However, we were only able to document 6 patients who had septic arthritis from more than 800 who received a renal transplant at our institution over an 18-year period. Furthermore, only 16 other cases of infectious arthritis have been reported in the literature. All of our patients had an apparent predisposing factor and 3 patients had prior infection with the same organism. The knee was the most commonly infected joint. The initial synovial fluid white blood cell count was usually greater than 30,000 cells/mm3, but 1 patient with viral arthritis initially had noninflammatory fluid. The peripheral blood white blood cell count may not be elevated. All of our cases of initial joint infection occurred by 18 months posttransplant. Blood cultures were positive in 3 of 4 patients with bacterial infection. Followup of these 6 patients averaged 4.3 years. Numerous other rheumatologic syndromes and disorders peculiar to the posttransplant period may mimic a septic joint. Consequently, despite the low frequency of occurrence of septic arthritis, persistent attention to the locomotor system in the transplant patient is warranted.